As is customary, the Board meeting began its 52^nd session with the report by the Executive Director (ED), who reviewed the Secretariat's activities over the past six months. He began his speech by depicting a gloomy and challenging environment: effects of the climate change on people’s health and condition, conflict and challenging humanitarian situations, growing erosion of human rights and pushback against gender equality and the economic pressures on both donor and implementing countries.   Amidst the challenging picture, Peter Sands highlighted the successes of the first semester in terms of grants’ approval, Grant Cycle 6 (GC6) absorption, and achievement in Key Performance Indicators (KPIs). Finally, the ED analyzed the challenges of 2025, a key year in terms of implementation and resource mobilization.   Progress against 2024 priorities   Implement Grants for Maximum Impact   The Executive Director started his report with some financial considerations (Figure 1), celebrating two main successes:

• GC7 has got off to a good start with $2 billion (15%) of total allocation disbursed by the end of September 2024.
• GC6 grant closure process indicates that the GF has exceeded the management target of 85% in-country absorption (ICA), well above the KPI.

  The progress of the partnership in achieving impactful financial performance is exemplified by West and Central Africa, with GC6 ICA above 88% compared to 77% in GC5.  

Figure 1: Total disbursements by year: 2018-2024 and C19RM

  He made a specific emphasis on RSSH investments, both implemented through the COVID-19 Resource Mobilization (C19RM) funds and the GC7. Combining C19RM Resilient and Sustainable Systems for Health and Pandemic Preparedness and Response (RSSH-PPR) investments and RSSH investments from country allocations and catalytic priorities, the Global Fund is now investing more in health systems than ever before (Figure 2). GC7/C19RM RSSH-PPR investments during the GC7 period will be approximately $5.9 billion (including direct and contributory RSSH, using the recently revised definitions endorsed by the Strategy Committee). This means about 40% of grant investments during the GC7 period will be directed towards RSSH-PPR. As RSSH grants are long-term investments that require time to be implemented, Peter Sands announced that the Secretariat had proposed support execution of this massive scale-up of health systems investments, and established an RSSH-PPR Implementation Acceleration initiative, to provide extra support, monitoring and to resolve bottlenecks.  

Figure 2. Total investments in RSSH-PPR: GC5-GC7 ($ billion)

  The Executive Director then shared his analysis of other important issues such as the growing necessity to fund emergency interventions due to the increasing frequency of crisis, caused by climate change, conflict or disease outbreaks like mpox. He announced that so far this year, the Secretariat has released $14.2 million from the Emergency Fund, representing 95% of initial Emergency Fund capacity for GC7. In October, the Audit and Finance Committee approved replenishing the Emergency Fund with a further $30 million from Portfolio Optimization, alongside an additional $45 million for critical emerging needs from Unfunded Quality Demand (UQD). Some countries have also used reprogramming to respond rapidly to crises. As an example, the ED mentioned the efforts made to respond to the mpox outbreak, where over $19 million from C19RM were provided to the Democratic Republic of Congo, Rwanda, Ghana, Côte d'Ivoire, Uganda, Liberia and Burundi through a combination of reprogramming and Portfolio Optimization.   Peter Sands highlighted the increasing pressures on the space for civil society and communities and the worrying backlash against human rights and gender equality in the programs funded by the Global Fund. To tackle this worldwide movement, the ED sees part of the response in the partnership, including multilateral partners, donor and implementer governments, civil society and communities, and the private sector. According to him, there is hope as demonstrated by the achievements of the Breaking Down Barriers initiative, that delivered results in terms of removing barriers to access, even in difficult contexts.   Strengthen Organization Effectiveness and Adaptability   The ED emphasized the efforts made by the Secretariat to improve efficiency and effectiveness in the Secretariat’s processes, and in adapting the organization structure and resourcing to evolving challenges and priorities. In that sense, technology and innovation are being mobilized to optimize the use of resources. Human resources are also impacted by these efforts, to increase organizational agility and better reflect business needs. To do so, there has been a deliberate shift away from permanent contracts to defined duration or temporary contracts: at the end of September 2024, Secretariat workforce on permanent contracts represented 61% of the total, compared to 80% at the end of 2019. At the end of September 2024 said Peter Sands, “only 18% of new hires have been recruited on permanent contracts”. He acknowledged that meanwhile this shift increases organizational agility, it has also contributed to the rising concerns about about job security, career development and future employment prospects seen in both the employee engagement survey and the Ombudsman’s report, an aspect covered by our article on employee mental health at the Global Fund.   With the appointment of Michelle Beistle as the new Ethics Officer in March 2024, the Secretariat has stepped up the pace of progress in embedding an ethical culture and increasing the organizational resilience to ethics related risks. For example, 39 Principal Recipients (PRs) in the highest risk countries are implementing protection from sexual exploitation, abuse and harassment (PSEAH) capacity building plans, and 27 PRs in the second tier of countries are undergoing PSEAH capacity assessments as the second phase of the PSEAH capacity assessment and building project that will encompass all Global Fund PRs. The Ethics Office has conducted training for 130 PSEAH Focal Points in Asia-Pacific, and three countries are currently piloting CCM-led communications campaigns to increase PSEAH awareness among beneficiaries. A total of 22 new SEAH cases have been opened this year to date. In addition, the Ethis Office is updating and clarifying GF’s standards for ethical behavior in the Code for Employees, the Employee Handbook and associated policies, and are developing and implementing risk-based training programs. Our newsletter recently featured coverage on the issue of Global Fund and SEAH.   Another interesting mention was the significant progress made in GF’s support to countries on Public Financial Management (PFM) in 2024, funded in part by additional earmarked private sector contributions. While past efforts on PFM have focused primarily on implementer governments’ management of Global Fund grants, the Secretariat is working on building more effective approaches to mobilizing and deploying domestic funds alongside external funds takes time, as an essential foundation for robust sustainability planning and implementation. As part of this effort, Peter Sands mentioned the high-level meeting organized with budget directors and other key stakeholders from 14 countries (Figure 3), which we covered in Enhancing health sector management. Key outcomes included commitments to better align financial planning and investment, improve budget formulation and execution, and strengthen monitoring and evaluation mechanisms.  

Figure 3

  In terms of partnership, the Secretariat has maintained its efforts to feed the partnership with a wide range of multilateral and bilateral partners, including by signing a number of memorandums of understanding to formalize coordination modalities, expand the Global Fund’s ability to jointly invest in shared priorities and highlight priorities for coordination and collaboration. During 2024, effort was made to deepen the collaboration with Gavi and GFF, (Uniting Forces for Global Health: The Transformative Partnership of the Global Fund, Gavi and the Global Financing Facility (GFF)), but results were not sufficient. Four main areas were addressed:  

• Enhancing collaboration on malaria, particularly around the optimal deployment of the RTS’S/R21 vaccines (Gavi, Global Fund only).
• Deepening collaboration on RSSH-PPR.
• Enhancing coordinated engagement with countries.
• Exploiting opportunities for realizing synergies in enabling functions (Gavi, Global Fund only).

  Peter Sands regretted that “since the formal establishment of these four workstreams in October 2023, we have made some progress on each of them but rather less than we hoped for, perhaps reflecting different levels of prioritization and ambition across the different organizations”. As a mitigation measure, a Joint Committee Working Group (JCWG) – mandated to focus on the first three workstreams – was established and met for the first time on 1 October, 2024.   Finally, as for resource mobilization, conversion of Seventh Replenishment pledges has been a priority, alongside preparation for the Eighth Replenishment. As of the end of September 2024, ED announced that the Secretariat has successfully converted 51% of Seventh Replenishment pledges into cash, compared to 41% at the same point in the previous cycle. As of the same date, cash conversion of adjusted Sixth Replenishment pledges stands at 99%. During 2024, the GF secured almost $100 million in additional pledges for GC7, primarily from private sector donors.   2025: A year of great danger?   The ED warned that 2025 will be challenging:

• In terms of implementation (as the second year of GC7 and the final year of C19R as 2025 could well see another record year of disbursements).
• The Eighth Replenishment to be held in an extremely demanding context, with donor official development assistance (ODA) budgets under acute pressure and development assistance for health (DAH) budgets under particular scrutiny given the competing demands from climate change as well as conflict driven humanitarian crises and refugee flows.
• Geopolitical tensions.
• Economic stresses and the ever more evident impact of climate change.
• The backlash on human rights and gender that impedes access to healthcare.

  In this context, the ED shared the Secretariat’s strategy to ensure impact and performance:  

• Addressing the challenge of maximizing the opportunity from market shaping. Peter Sands took the example of the dual active ingredient nets over the last 12 months as a proof that innovations requires intense coordination between multiple implementation, technical and development partners on an end-to-end basis, plus the agility to navigate the inherent uncertainties. Long-acting injectable pre-exposure prophylaxis (PrEP) is another example of potentially game-changing opportunity to bring forward the end of AIDS as a public health threat, as long as the manufacturers deliver on their expressed intent to enable rapid, affordable and equitable access at scale. Adding highly effective injectable PrEP options to the existing HIV prevention toolkit will allow people to choose the protection option that best fits their needs.
• Ensuring rapid and effective implementation of RSSH interventions, given the unprecedented scale and breadth of our current investments through GC7 and C19RM. Peter Sands acknowledged the risk that some countries will not be able complete full implementation of their C19RM-funded investments by the Board-approved deadline of December 2025. “There is a need to consider whether selective extension of the C19RM utilization deadline makes sense. This will be a Board decision” he said.
• Ensuring the continued effectiveness of community-led and rights-based programming in a context where human rights and the space for community engagement are under threat in many countries. While many of the challenges in this area are specific to countries and communities, the broader geopolitical context is also crucial. The global pushback on human rights and gender is widespread, well-organized and well-funded. “Fighting back is a prerequisite for delivering on our mission and will require determination and courage from across the partnership” stated the ED.
• Accelerating progress towards more integrated and people entered service delivery models recognizing that there is more to be done to address several issues at once through integrated interventions such as polyvalent community health workers, integration of prevention of mother-to-child transmission services in broader maternal/neonatal packages, and integration of HIV prevention in broader sexual health services, alongside contraception and prevention of sexually transmitted infections. Peter Sands added: “perhaps the most fundamental challenge is ensuring that taking a broader approach does not overly diffuse resources, overstretch implementation capacities, or dilute the focus on outcomes that has powered our success so far”.
• Responding to the increasing frequency of disruptions from conflict and climate change that hamper the progresses towards the achievement of Operational Due Diligence 3.

  Delivering a Successful Eighth Replenishment   The Global Fund’s Eighth Replenishment, which will raise money for GC8 (2027-2029), will culminate in September/October 2025. This replenishment will therefore determine GF’s trajectory towards the SDG 3 goals for 2030.   Peter Sands acknowledged that the majority of the GF’s biggest donors have cut (or are intending to cut) overall levels of ODA. Global health has lost ground against climate change and conflict-related humanitarian assistance (including refugee costs) in the ranking of donor priorities. Some donors have switched emphasis from multilateral to bilateral channels, often linked to the advancement of national agendas, such as trade or migration. And even within global health, there is increased competition for resources across different themes (e.g., pandemic preparedness, antimicrobial resistance, regional manufacturing, universal health care (UHC)), and a queue of global health agencies seeking financial resources over the next few months (including Gavi, WHO, the Pandemic Fund and the International Development Association).   Peter Sands fears that the Investment Case, to be published in early 2025, will undoubtedly show a massive difference between overall funding needs and prospective overall funding from all sources. “At one end of the spectrum, for TB, the Global Fund provided 76% of total external funding, but given that most TB programs were domestically financed, only 15% of total funding across lower- and middle-income countries. At the other end, for malaria, the Global Fund provided 62% of total external funding and given the paucity of domestic resourcing in the highest burden countries, about 39% of total funding in malaria endemic countries. For HIV, the Global Fund provided 28% of external funding (since PEPFAR was the leading source) and 11% of the total. The negative impact of a shortfall of investments would then be very different depending on the diseases, and the geography. “In some of the very poorest and most conflict-ridden countries and regions in the world, such as in the Sahel, the Global Fund can represent the largest source of external funding for health and can be comparable to government spending” explained Peter Sands.   Conclusion   Much of this discussion is framed as a debate about sustainability. At one level the problem statement for sustainability is straightforward to articulate: How do we ensure sustained progress against the Global Fund’s overarching mission of ending HIV, TB and malaria as public health threats? Yet below this, there are many differences of nuance and emphasis. For some stakeholders, the emphasis is on how to sustain progress given the prospect of potentially sharp reductions in donor funding. This angle puts the primary emphasis on domestic resource mobilization. For others, the priority is as much about how to sustain donor support for long enough to enable countries to fix the glaring inadequacy of other funding sources.   Peter Sands concluded: “the sustainability question needs to be addressed, showing how financial responsibility for the fight against the three diseases can be progressively shifted from external funders to domestic resourcing is essential. Donors are increasingly impatient and demanding a pathway towards eventual exit, or at least, a light at the end of the tunnel. Implementer governments want greater control of health priorities and implementation modalities. Yet, we must also confront the epidemiological, economic, programmatic and political realities. Sustainability planning built on wishful thinking will not result in the sustainability of progress against the three diseases; instead it will result in making the diseases themselves sustainable. There is a risk that we drift away from considering what must be done to ensure continued reductions in deaths and infections towards tacitly accepting solutions that keep deaths to a level that is in some way politically “tolerable” but do not deliver the necessary progress in reducing transmission. This again is a path towards the wrong kind of sustainability – of making the diseases themselves sustainable. The danger is that with pathogens as formidable as HIV, TB and malaria, there is no middle ground: If we are not winning, we are losing.”   Constituency Feedback   The Constituency representatives thanked the Executive Director for his report.   Some members expressed deep concern over the growing discriminatory environments. They advocated for an increased support for key and vulnerable populations who are marginalized, criminalized and in some contexts, invisible, which are only worsening. They questioned the impact of the Global Fund’s diplomatic voice and how is this diplomacy holding countries accountable for their actions and inactions, which put at risk key and vulnerable populations.   Some participants raised their concerns over the Ombudsman Report, urging the Management Executive Committee to take responsible steps to guarantee a respectful working environment, as well as suggesting a major engagement from the Ethics Department.   The emphasis put on health system resilience has been welcomed by the Constituencies as it impacts both the effectiveness of the response to emergencies (conflict, outbreaks or climate change effects) and guarantees sustainability. They highlighted the challenging times in which the 8^th Replenishment will take place and urged the Secretariat to keep the Board engaged in the preparations to ensure synergies. Nevertheless, some speakers regretted the lack of clarity given to the priority put on RSSH in GC8, despite the Secretariat’s commitment to leveraging all levers to improve the impact of RSSH in GC8. They urged the ED to present concrete steps and new approaches on how to impactfully embed RSSH in GC8: e.g. through upfront (binding) communication to countries of RSSH-expectations/amounts, single funding requests, Qualitative Adjustments, longer implementation cycles, adequate Global Fund Secretariat staffing and co-financing.   The Constituencies also shared their concerns about the ending of C19RM that would significantly impact on RSSH without any clarity on the compensation offered on GC8. As the remaining implementation timeline for C19RM investments is short, ED’s suggestion of selective extensions of the C19RM implementation period has been highlighted as an interesting perspective.   Some participants thanked Peter Sands for his effort to integrate climate change effects into the strategic thinking and urged the Secretariat to include it in all aspects of GF’s engagement.   Given the current environment, all participants welcomed the efforts made by the Global Fund, Gavi and GFF to provide more coherent and integrated support to countries in order to build more resilient and equitable health systems, through the Joint Committee Working Group. Participants called for a joint work plan for implementation of the various workstreams. Given the strategic importance of accelerated collaboration between the 3 GHIs, they encourage the Secretariat and the Joint Committee Working Group to provide periodic briefings to the Strategy Committee and Board on the progress made and challenges encountered in this regard.